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Four-year outcome evaluation of a free referral service for uninsured New Yorkers

Geoffrey Steinberg, Psy.D., Executive Director September 2011

2011 TherapySafetyNet

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TherapySafetyNet: Four-Year Outcome Evaluation of a Free Referral Service for Uninsured New Yorkers Geoffrey Steinberg, Psy.D., Executive Director September 2011 Introduction An estimated 2.5 million New Yorkers do not have employer-sponsored health insurance (New York State Department of Health, 2009), yet do not qualify for publicly funded programs such as Medicare or Medicaid. Approximately 1.2 million of these uninsured people live in New York City. The uninsured include temporary workers, part-time workers, unemployed or self-employed individuals, and workers whose employers choose not to provide health insurance coverage. TherapySafetyNet is a free referral service that aims to bridge this gap in mental health care for uninsured New Yorkers. Since its inception in September 2007, TherapySafetyNet has developed into a coalition of psychologists and social workers in private practice, each of whom agrees to work with a limited number of uninsured clients at reduced fees according to a sliding scale. TherapySafetyNet offers private practitioners an organized way to fulfill the ethical aspiration to devote some portion of ones professional work for minimal compensation. Over the past four years, 52 clinicians have participated as professional members of TherapySafetyNet. Our current membership consists of 12 clinicians, four of whom serve as Referral Coordinators on a weekly rotation. Each of our professional members is licensed by the state of New York and is committed to social responsibility, including caring for those who lack insurance coverage for mental health. TherapySafetyNet is neither a mental health clinic nor a group practice. Each participating clinician maintains full autonomy over his or her private practice while agreeing to basic terms of membership, including agreeing to work with at least one eligible client at the lowest point of the sliding scale. Participating clinicians agree to maintain the reduced fee as long as the client remains uninsured. As a coalition of clinicians in private practice united by a common interest in helping an under-served population, TherapySafetyNet operates by way of the volunteer efforts of its participating clinicians. An estimated 1,000 volunteer hours have been contributed thus far to TherapySafetyNets operations, including web design, public relations, and referral coordination activities. The costs of TherapySafetyNets operations are covered by annual dues payments by participating clinicians.

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Demographics of Prospective Clients Prospective Clients Since its inception in 2007, TherapySafetyNet has recorded 300 unique outcomes from prospective clients who have requested our services. To request a referral from TherapySafetyNet, prospective clients are now required to complete a secure application form on our website, In the first four years, 307 requests for services have been recorded on the current application form, as well as four requests recorded on an earlier version of the application. Some of these requests were duplicates from the same individual, which accounts for the fact that the absolute number of records in our set of applications is higher than the number of outcomes recorded. Prior to formalizing the application process, prospective clients were offered the choice of completing the online application form or sending an email to TherapySafetyNet to request a referral. Demographics of those clients who inquired by email are not available; however, the outcomes of email inquiries are included in this analysis. An unknown number of prospective clients referred themselves directly to participating therapists who accepted them into their practices under TherapySafetyNets auspices. Participating therapists provided us with information about the outcomes of only eight such direct referrals, but it is possible that more occurred for which outcome data was never reported. In the interest of developing a more consistent application process and obtaining more accurate measurements of our service, we removed contact information from therapist profiles on our website so that all requests for services must now be made through the secure application form. Demographic information as reported here is based on a subset of 224 completed responses to the current application form. When completing the application form, prospective clients agreed that the protected health information they choose to provide about themselves may be reviewed by any of the mental health professionals who participate in TherapySafetyNet.

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Age Requests for reduced fee services have come from a relatively young population. A full 86 percent of inquiries were from people under the age of 40, and 53 percent were from people under the age of 30, as shown in Figure 1. Figure 1. Age distribution.

This distribution may be reflective of a disproportionate number of young people lacking health insurance, as well as the fact that TherapySafetyNet is an online service. Given the fact that Medicare eligibility begins at age 65, it is not surprising that not a single request has come from prospective clients age 65 or older.

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Gender A gender difference was observed among completed applications. Prospective clients were 70 percent female and 30 percent male, as shown in Figure 2. Figure 2. Gender distribution.

This disparity in the gender of prospective clients may be reflective in part of the fact that our membership consists mostly of female clinicians. We would like to increase the representation of male clinicians, as some men may have a preference for working with a male therapist.

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Residency The vast majority (97.4%) of prospective clients were New York state residents, showing that in most cases TherapySafetyNet is reaching the population we intend to serve, as shown in Figure 3. Figure 3. New York state residency status.

When responding to the handful of prospective clients residing in states other than New York, Referral Coordinators encouraged them to find comparable resources in their home states.

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Insurance Status While TherapySafetyNets mission is to provide psychotherapy referrals for uninsured people, approximately 16 percent of inquiries came from prospective clients who do have health insurance, as shown in Figure 4. Figure 4. Insurance status.

Prospective clients with insurance were not eligible for reduced fee services through TherapySafetyNet. Referral Coordinators either offered insured individuals assistance in accessing their benefits or referred them to a participating clinician who was in-network for their insurance policy.

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Presenting Concerns To match prospective uninsured clients to the specialties of participating clinicians, applicants were asked both to write a narrative description of their concerns and to make a selection from a list of 46 problems. Prospective clients were free to check as many items from the list as they felt applied to them. Four concerns were most frequently endorsed: relationship issues (58.1%), anxiety disorders/phobias (49.2%), stress management (46.4%), and depression (45.3%). The top fifteen concerns are shown in Figure 5. Figure 5. Self-reported concerns.

This list of concerns is identical to that from which participating clinicians may indicate their top specialties, thus allowing Referral Coordinators to match prospective clients presenting problems with participating therapists areas of expertise.

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Referral Sources Making our services known to the vast population of uninsured New Yorkers has been one of our greatest challenges. When asked how they heard about TherapySafetyNet, 68 percent of prospective clients stated they found TherapySafetyNet by way of an Internet search, as shown in Figure 6. Figure 6. Referral sources.

When a prospective client found TherapySafetyNet by way of an Internet search, this was usually the result of paid keyword advertising. Professional membership dues have paid for over $1,500 in advertising costs. Our public relations efforts are aimed at reducing these costs by increasing free forms of online visibility as well as word-of-mouth referrals. Thus far, only 32 percent of applicants reported that they heard about TherapySafetyNet through referral sources other than Internet searches, including referrals from professionals, recommendations from friends, and links from other websites.

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Outcomes of Prospective Client Inquiries The outcome data reported here are based on 300 applications that prospective clients submitted to TherapySafetyNet between September 2007 and August 2011. These applications included email inquiries, direct referrals, and prospective clients' responses to both old and new versions of the client inquiry application. Eligibility Screening Referral Coordinators determined each prospective clients eligibility for a reduced-fee referral to a participating TherapySafetyNet clinician on the basis of the following criteria: 1. 2. 3. The application was complete. The prospective client was a New York state resident. The prospective client reported that he or she did not have health insurance, or if they were insured, their health plan was one of the few that are allowed by law to exclude mental health benefits, such as Healthy NY and specific Group Health Incorporated (GHI) plans. The fee that the prospective client reported they could afford per session was equal to or greater than the lowest fee on our sliding scale. Self-reported gross income was less than $60,000 per year. The prospective client was willing to provide proof of income in the form of their most recent tax return.


In February 2011, two additional criteria were introduced: 5. 6.

With the introduction of these two additional criteria, we initially asked prospective clients to provide proof of income prior to their first meeting with the therapist to whom they were referred. Very few prospective clients were willing to provide us financial documentation sight unseen. Therefore, in June 2011 we made a further modification to the referral process such that the income verification step was included in the initial consultation with the therapist to whom the client was referred.

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Eligible Prospective Clients On the basis of the eligibility criteria listed above, 115 (38.7%) prospective clients were determined to be eligible for our services, as shown in Figure 7. Figure 7. Eligibility for reduced fee referrals: Was this prospective client eligible for a reduced fee referral to a TherapySafetyNet clinician?

Of the 115 prospective clients determined to be eligible, 103 (89.6%) were referred to a participating TherapySafetyNet therapist for reduced fee psychotherapy, as shown in Figure 8. The majority (71.4%) of prospective clients expressed no preference for a particular therapist among our membership. In such cases, the Referral Coordinator issued an email to all members with a brief description of the client, with identifying information removed. If multiple therapists expressed an interest in accepting the referral, the Referral Coordinator assigned a therapist from among those responding whom they believed would be the best match.

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In the minority of cases (28.6%) in which a prospective client expressed a preference for a specific therapist, the Referral Coordinator contacted the requested therapist, and if he or she agreed to accept the referral, then the client was assigned to that therapist. If the requested therapist did not accept the referral, the Referral Coordinator contacted all participating therapists to attempt to find another match. Figure 8. Outcomes of eligible prospective clients: Was this eligible, uninsured client referred to a participating TherapySafetyNet therapist?

The remaining 12 prospective clients, while technically eligible, were not referred to one of our participating therapists for a variety of reasons, including lack of fit between the clients presenting problems and therapists areas of expertise, scheduling incompatibility, and other factors that prevented completion of the referral process. For example, some clients only wanted to be seen by a psychiatrist, and no psychiatrists are included among our participating clinicians. In such situations, Referral Coordinators offered the prospective client other referral options tailored to their needs.

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Ineligible Prospective Clients As a free referral service, TherapySafetyNet has assisted many prospective clients with securing local mental health services, whether the ultimate disposition was a referral to one of our participating clinicians or a referral to outside community mental health services. In response to each application for services, we attempted to find the best possible outcome while also ensuring that our membership was receiving referrals appropriate to their practices. As shown earlier in Figure 7, 182 prospective clients (61.3%) were not eligible for a reduced-fee referral to a participating TherapySafetyNet clinician. A variety of factors may disqualify a prospective client, including incomplete applications, having health insurance, not being a New York resident, having too high an income, or not being able to afford the lowest fee on the sliding scale. Outcomes of ineligible inquiries are presented in Figure 9. Figure 9. Outcomes of prospective clients not eligible for TherapySafetyNet.

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Insured Prospective Clients Although TherapySafetyNet is designed to assist uninsured clients, 60 inquiries were received from prospective clients who reported that they do have health insurance. We have encountered many people who have health insurance coverage but are unaware that psychotherapy is covered by their policy. In these instances, the Referral Coordinator responded by offering information about how to access their mental health benefits. Of the insured prospective clients who completed the application, 40 were offered assistance in how to access their benefits. Another 15 were referred to participating TherapySafetyNet clinicians who happened to be participating providers with the prospective clients insurance policy. In these situations, the prospective client was not eligible for reduced fee services, but was offered the option of working with one of our participating clinicians according to the terms of their insurance policy, including any applicable deductibles and co-payments. Remaining insured prospective clients did not complete the application, and thus it was not possible to respond to their inquiries. Uninsured Prospective Clients Referred to Community Resources Among 78 of the applications received, the prospective client reported that the most they felt they could afford per session was less than the lowest fee on our sliding scale. In such instances, the Referral Coordinator attempted to ascertain whether the prospective client could afford a bit more. If so, the referral process continued. However, in the vast majority of cases, the prospective client either did not respond to our question or responded by affirming that they were unable to afford the lowest fee on the sliding scale. We therefore offered these prospective clients a list of other low-fee mental health services in the community. TherapySafetyNet is focused on serving uninsured New Yorkers. As shown earlier in Figure 3, some applications were from prospective clients living in other states. In 10 instances of out-of-state applications, the Referral Coordinator suggested the prospective client search for comparable resources in their home state. Starting in February 2011, TherapySafetyNet began requiring that prospective clients demonstrate financial need for our services. Since that time, 18 prospective clients were determined ineligible because they were unwilling to provide proof of income to determine their eligibility. An additional seven individuals self-reported income that was too high to be eligible for our sliding scale, and thus conceivably could afford full-fee services even though they were not insured.

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Remaining instances of ineligible prospective clients involved incomplete applications, many of which included no valid contact information, such that it was impossible for Referral Coordinators to ask for additional information to determine eligibility. Discussion Outreach Considering that an estimated 1.2 million uninsured people are living in New York City, 300 completed applications in four years suggests TherapySafetyNet is reaching only a small fraction of the population we intend to serve. One of our biggest challenges has been to make our referral service more widely known. To this end, we have conducted outreach to other organizations that may encounter uninsured New Yorkers, such as the National Alliance on Mental Illness (NAMI). Other outreach efforts include our Internet presence, which includes listings with organizations that serve local artists, such as The Field, Dance Elephant, and the Stage Directors and Choreographers Society. TherapySafetyNets Facebook page ( receives anywhere from 25 to 50 visitors per week, and we have recently added a feature that allows prospective clients to complete an application for services directly on Facebook. Beyond these efforts to make our referral service known, our need to increase our public visibility remains strong. Professional Membership TherapySafetyNet has experienced considerable turnover among our coalition members. In the beginning, some participating therapists seemed not to understand fully how TherapySafetyNet differs from other websites that present directories of therapists in private practice. For some time, we faced differences in expectationssome therapists were willing to reduce their fees slightly, but not far enough to meet the actual needs of uninsured people. By now, we have addressed this discrepancy through introduction of the sliding scale as well as more rigorous membership requirements, including a face-to-face interview to insure that clinicians joining our coalition understand the scope of our mission. Further Study This report has focused on the outcomes of applications for services that TherapySafetyNet has received. Only recently has our evaluation process expanded to include following up with participating therapists to determine what happened after the referral was made. From a small sample of 30 referrals, 80 percent of clients referred to a participating clinician attended the initial

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consultation. We will continue to track these outcomes over a larger sample of referrals in the coming year. Conclusions Over four years, 15 to 20 prospective clients contacted TherapySafetyNet each month for help securing a referral for affordable therapy. About one-third of these applicants were determined to be eligible for our services and were referred to a participating clinician for psychotherapy at a reduced fee. The remaining two-thirds were referred out. Those prospective clients who were ineligible because they had health insurance were educated as to how to access their benefits, while those who were ineligible and uninsured were referred to other low-cost mental health resources in the community. Since its inception, TherapySafetyNet has served a valuable role in metropolitan New York by assisting prospective clients in finding mental health services they can afford. Of the 300 outcomes recorded since 2007, we have referred 103 uninsured clients to participating psychologists and social workers in private practice at significantly reduced fees, thus connecting uninsured New Yorkers with psychotherapy of a quality that would otherwise be inaccessible and unaffordable. TherapySafetyNets team of Referral Coordinators has provided an additional service to the community by serving as a clearinghouse of resources and education for prospective clients seeking mental health services. These outcomes have included referring 58 uninsured people to other mental health services in the community and assisting 55 insured people with accessing their insurance benefits for psychotherapy. These findings point to the need to make criteria for TherapySafetyNet eligibility more transparent on our website. Additionally, we will be posting listings of other community mental health resources for the uninsured and information about how insured people may access their benefits for mental health. TherapySafetyNet will continue our mission of connecting uninsured New Yorkers with socially responsible therapists. We eagerly await changes to the healthcare system that may ultimately render our services obsolete once every New Yorker has the insurance coverage required to address their mental health needs. Reference New York State Department of Health (2009). Uninsured New Yorkers Urged to Sign up for Health Insurance During 'Cover the Uninsured Week.' Press Release.

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